Provider Demographics
NPI:1881660025
Name:JOHNSTON, WILLIS BRADLEY (DPM)
Entity Type:Individual
Prefix:DR
First Name:WILLIS
Middle Name:BRADLEY
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5403
Mailing Address - Country:US
Mailing Address - Phone:405-280-5550
Mailing Address - Fax:
Practice Address - Street 1:701 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5403
Practice Address - Country:US
Practice Address - Phone:405-280-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK132213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100780620AMedicaid
OKT40754Medicare UPIN